Role of sentinel lymphadenectomy in thin invasive cutaneous melanomas.

PURPOSE: Regional lymph node status is the strongest prognostic determinant in early-stage melanoma. Lymphatic mapping and sentinel lymphadenectomy (LM/SL) is standard to stage regional nodes because it is accurate and minimally morbid, yet its role for thin (相似文献   

Sentinel node guided surgery for melanoma in the head and neck region

Sentinel lymph node biopsy may be more technically challenging for melanoma of the head and neck compared with other locations because of the complex lymphatic drainage patterns. This study demonstrates the value of sentinel node biopsy for head and neck melanoma, and highlights the associated difficulties. Thirty consecutive patients with primary cutaneous melanoma of the head and neck (n=26) or draining to the neck (n=4) underwent preoperative lymphoscintigraphy. This was followed by intraoperative lymphatic mapping using blue dye alone (n=8) or in combination with a hand-held gamma probe (n=22) and sentinel lymphadenectomy. Modified neck dissection was performed in all patients with positive sentinel nodes. The study population had a male predominance (73%). Most lesions were nodular and were not ulcerated. In two patients (6.2%) preoperative lymphoscintigraphy failed to demonstrate the draining nodes, which were retrieved by surgery, and in two patients (6.2%) the sentinel node was not found at surgery despite preoperative visualization. Overall, the sentinel node was identified 93% of the time: in seven out of eight cases (88%) using blue dye alone, and in 21 out of 22 cases (96%) using a combination of blue dye and gamma probe. Four out of 28 basins were deemed positive for metastases. Twenty-three of the 24 patients with negative sentinel nodes were free of disease at a median of 31 months (range 9-91 months). There was one false-negative case salvaged by surgery. The sentinel node technique is technically demanding but advantageous for most patients with head and neck melanoma. Identification rates seem to be better when preoperative lymphoscintigraphy is combined with intraoperative blue dye mapping and a hand-held gamma probe. The relative contribution of each component could not be determined.     

Sentinel node biopsy for melanoma: a study of 241 patients

The aim of this study was to evaluate the sentinel node biopsy (SNB) technique for melanoma using both radiocolloid and blue dye in 241 clinically N0 patients with melanomas >1.0 mm, or thinner lesions exhibiting regression/ulceration. We showed that an increase in injected radioactivity increased both the number of visualized nodes at lymphoscintigraphy and the number of SNs removed surgically. At least one SN was removed in 98% (236) of patients, and all nodes were identified with the probe. Seventy-four per cent of the 194 patients injected with blue dye had stained SNs. In 46% (144) of the lymph node basins, there was a discrepancy between the nodes visualized at lymphoscintigraphy and the nodes removed at surgery. There were 38 unusually located nodes. Only eight of these were removed surgically; none contained metastases. SN metastases were detected in 22% (53) of patients. There were nine haematoxylin and eosin (HE)-negatives, all of which were found by immunohistochemistry. The false negative rate for the SNB procedure was 4% (2/55). The complication rate was 6% after SNB and 29% after complete node dissection. In conclusion, SN status is a strong prognostic factor in melanoma patients, and SNB has made the approach to radical lymphadenectomy more rational.     

Sentinel node biopsy in cutaneous melanoma: correlations between melanoma prognostic factors and sentinel node status

This study aims to correlate the most important prognostic factors of primary melanoma with sentinel node (SN) positive for metastases. We have enrolled 84 patients subjected to sentinel node biopsies for cutaneous melanomas of Breslow's thickness > or = 0.75 mm by using an intra-operative gamma probe after lymphoscintigraphy, without blue dye support. SN metastases were reported in 27% of cases (14% by histology and 13% by immunohistochemistry). By chi-square test Breslow's thickness > 2mm (p= 0.004), IV and V Clark's level (p= 0.02), ulceration (p= 0.05) and high mitotic rate (p= 0.05) were statistically significant (p < 0.05) with reference to SN positive for metastases, unlike the site of cutaneous melanoma, vertical growth phase, tumour infiltrating lymphocytes, regression and vascular invasion. Breslow's thickness remains the first prognostic factor to be considered for sentinel node biopsy in cutaneous melanoma, but other markers must be carefully estimated.     

No indication for performing sentinel node biopsy in melanoma patients with a Breslow thickness of less than 0.9 mm

In thin melanomas, the involvement of regional nodes is very uncommon. Recent sentinel node (SN) studies have confirmed the absence of positive regional lymph nodes in melanomas < 0.76 mm and a 5% positivity in melanomas between 1.0 and 1.99 mm. The chance of regional lymph node involvement - and therefore whether it is relevant to perform the SN procedure - seems to depend on the Breslow thickness of the primary tumour. However, a Breslow thickness cut-off point has not yet been established. We evaluated a melanoma population that had undergone an SN procedure to determine this point, so that the procedure can be restricted to a smaller group of patients in future. In a total of 348 patients with proven American Joint Committee on Cancer (AJCC) stages I or II cutaneous melanoma with a Breslow thickness > or = 0.5 mm the triple technique was used, consisting of preoperative visualization of the lymph channels from the initial site of the melanoma towards the SN by (dynamic) lymphoscintigraphy, intraoperative visualization of those particular lymph channels and nodes with blue dye, and a gamma probe to measure accumulated radioactivity in radiolabelled lymph nodes. In melanomas thinner than 0.90 mm, no positive SN was found (95% confidence interval 0-5%). This group consisted of 75 patients (22%), with a median follow-up of 31 months. Our data suggest that this procedure need no longer be indicated for almost a quarter of the patient population, because the cut-off point for nodal involvement appears to be a Breslow thickness of 0.90 mm.     

Sentinel node biopsy in patients with cutaneous melanoma of the head and neck

Biopsy of head and neck sentinel nodes (SNs) can be technically problematic due to the unpredictable and variable drainage patterns of this anatomic region. The aim of the present study was to evaluate the feasibility of SN biopsy for cutaneous melanoma of the head and neck. We performed SN biopsy in 17 patients affected by stage I cutaneous melanoma of the head and neck on the basis of lymphoscintigraphy, blue dye and gamma probe. A total of 24 procedures were performed. Drainage to more than one lymphatic basin was observed in five patients (two basins in three cases and three basins in two cases) and in all cases SN biopsy was performed in all basins. The biopsy distribution by site was: six cervical nodes, five parotid nodes, four supraclavicular and submandibular nodes, three auricular and axillary nodes. The SN identification rate was 87.5% (21/24); metastases were discovered in four cases, with a positivity rate of 23.6%. At the time of writing, 1 patient is alive with local disease, 3 patients are dead and 13 are alive and free of disease with a follow-up ranging from 1 to 40 months (median, 21 months) following SN biopsy. In our opinion preoperative lymphoscintigraphy and the intraoperative use of a gamma probe are useful for the identification of lymphatic drainage of cutaneous melanoma of the head and neck.     

Checkpoint blockade and BRAF/MEK therapy in the therapeutic setting improved the overall survival after sentinel node biopsy: A retrospective study comparing patients with primary care between 1998-2009 and 2010-2017

Immunotherapies using checkpoint blockade and BRAF/MEK therapies have improved overall survival (OS) in patients with unresectable melanoma metastases. In this retrospective study, we aimed to demonstrate the resulting increase in melanoma-specific survival (MSS) and OS after the excision of primary melanomas (≥1 mm thick) and sentinel lymph node (SN) biopsy (SNB). Using Kaplan-Meier estimates and Cox models, we compared two consecutive cohorts. Patients in cohort 1 (N = 518) underwent SNB between 1998 and 2009, and patients in cohort 2 (N = 460) between 2010 and 2017, when checkpoint blockade and BRAF/(MEK) inhibition became available for the treatment of unresectable relapses. The median follow-up times were 120 and 73 months, respectively. While recurrence-free and distant metastasis-free survival rates remained very similar, MSS and OS increased in favor of cohort 2. The estimated 5-year OS rate of SN-positive patients increased by 14.3% (78.5% vs 64.2%, logrank test: P = .005). The MSS benefit was significant even with low SN tumor burden (metastasis diameter < 1 mm). On multivariate analyses, the risk-reduction in favor of cohort 2 was significant in the total population and in the SN-negative and SN-positive subgroups. In SN-positive patients, besides the availability of modern therapies, SN metastasis diameter and ulceration were independent factors of MSS and OS. Treatment of unresectable melanoma recurrences with modern drug therapies results in significantly higher survival rates in a population with SNB. The survival benefit measured from primary melanoma affects both the SN-positive and SN-negative subpopulations.     

Role of routine preoperative lymphoscintigraphy in sentinel node biopsy for breast cancer

Sentinel node biopsy (SNB) is rapidly emerging as the preferred technique for nodal staging in breast cancer. When radioactive colloid is used, a preoperative lymphoscintiscan is obtained to ease sentinel lymph node (SN) identification. This study evaluates whether preoperative lymphoscintigraphy adds diagnostic accuracy to offset the additional time and cost required. 823 breast cancer patients underwent SNB based on lymphoscintigraphy, intraoperative gamma probe detection, and blue dye mapping using 99 mTc-nanocolloid and Patent Blue V injected peritumourally. The SNB was followed by standard axillary treatment at the same operation. Preoperative lymphoscintigraphy was performed around 3 h after the radioisotope injection. Preoperative lymphoscintigraphy revealed SNs in 593 (72%) of the 823 patients imaged. SN visualisation on lymphoscintigraphy was less successful in large tumours and tumours involving the upper outer quadrant of the breast (P=0.046, P<0.001, respectively). Lymphoscintigraphy showed internal mammary sentinel nodes in 9% (62/707) patients. The SN was identified intraoperatively in 98% (581) patients who had SN visualised on preoperative lymphoscintigraphy, with a false-negative rate of 7%. In patients who did not have SN visualised on preoperative lymphoscintigraphy, the SN was identified at operation in 90% (204) patients, with a false-negative rate of 7%. The SN identification rate was significantly higher in patients with SN visualised on preoperative lymphoscintigraphy (P<0.001). SN identification rate intraoperatively using the gamma probe was significantly higher in the SN visualised group compared with the SN non-visualised group (95% vs. 68%; chi square (1 degrees of freedom (df)) P<0.001. There was no statistically significant difference in the false-negative rate and the operative time between the two groups. A mean of 2.3 (standard deviation (SD) 1.3) SNs per patient were removed in patients with SN visualised on preoperative lymphoscintigraphy compared with 1.8 (SD 1.2) in patients with no SN visualised on lymphoscintigraphy (P<0.001). Although SN visualisation on preoperative lymphoscintigraphy significantly improved the intraoperative SN localisation rate, SN was successfully identified in 90% of patients with no SN visualisation on lymphoscintigraphy. Given the time and cost required to perform routine preoperative lymphoscintigraphy, these data suggest that it may not be necessary in all cases. It may be valuable for surgeons in the learning phase to shorten the learning curve and in patients who have increased risk of intraoperative failed localisation (obese or old patients). A negative preoperative lymphoscintiscan predicts the inability to localise with the hand-held gamma probe. Therefore, if the SN is not visualised on lymphoscintigraphy then the addition of intraoperative blue dye is recommended to increase the likelihood of SN identification.     

Lymphatic mapping and sentinel lymph node biopsy in the management of primary cutaneous melanoma: report of a single-centre experience

AIMS AND BACKGROUND: Lymphatic mapping and sentinel lymph node biopsy provide important prognostic data in patients with early stage melanoma and are crucial in guiding the management of the tumor. We report our experience with lymphatic mapping and sentinel lymph node biopsy in a group of patients with primary cutaneous melanoma and discuss recent concepts and controversies on its use. PATIENTS AND METHODS: A total of 111 patients with stage I-II AJCC primary cutaneous melanoma underwent lymphatic mapping and sentinel lymph node biopsy from December 1999 through December 2004 using a standardized technique of preoperative lymphoscintigraphy and biopsy guided by blue dye injection in addition to a hand-held gamma probe. After removal, sentinel lymph nodes were submitted to serial sectioning and permanent preparations for histological and immunohistochemical examination. Complete lymph node dissection was performed only in patients with tumor-positive sentinel lymph nodes. RESULTS: Sentinel lymph nodes were identified and removed in all patients (detection rate of 100%), and metastases were found in 17 cases (15.3%).The incidence of metastasis in sentinel lymph nodes was 2.1%, 15.9%, 35.2%, and 41.6% for melanomas < or 1.0, 1.01-2.0, 2.01-4.0, and > 4.0 mm in thickness, respectively. Complete lymph node dissection was performed in 15 of 17 patients with positive sentinel lymph nodes, and metastases in non-sentinel lymph nodes were detected in only 2 cases (11.7%). Recurrences were more frequently observed in patients with a positive than in those with negative sentinel lymph node (41.1% vs. 5.3% at a median follow-up of 31.5 months, P < 0.001). The false-negative rate was 2.1%. CONCLUSIONS: Our study confirms that lymphatic mapping and sentinel lymph node biopsy allow accurate staging and yield relevant prognostic information in patients with early stage melanoma.     

Sentinel lymph node biopsy for cutaneous melanoma: results of 10 years’ experience in two regional training hospitals in the Netherlands

Background and objective

The Multicenter Selective Lymphadenectomy Trial (MSLT-I) demonstrated that the sentinel node (SN) status in cutaneous melanoma affects prognosis and that completion lymphadenectomy in SN-positive patients may improve survival. Our objective was to evaluate sentinel lymph node biopsy (SLNB) in two regional hospitals in the Netherlands.

Methods

Patients with localized melanoma were planned for wide excision and SLNB. Completion lymphadenectomy was recommended for positive SN status. Data were compared with the MSLT-I.

Results

A median of 2 (1–7) SNs were identified in 305 patients and complications occurred in 11%. Fifty-four patients (18%) demonstrated SN metastases and 45 underwent completion lymphadenectomy (20% additional metastases). Six patients with initially negative SN developed lymph node metastases (sensitivity 90%). Overall disease-free survival was 83% (SN-negative 91% vs. SN-positive 41%; p < 0.001) and melanoma-specific survival was 93% (SN-negative 97% vs. SN-positive 62%; p < 0.001). Multivariate regression analysis revealed the SN status to be the most significant predictor for recurrence and melanoma-related death.

Conclusion

Our results of SLNB are comparable to data from high-volume centers participating in MSLT-I. From a patient perspective, the false-negative SN rate of 10% and complication rate of 11% should be weighed against being informed about prognosis and having a possible therapeutic benefit from completion lymphadenectomy.     

Sentinel lymph node biopsy in melanoma patients with clinically negative regional lymph nodes--one institution's experience

The purpose of this prospective study of sentinel lymph node (SLN) biopsy in a large series of melanoma patients with clinically negative regional lymph nodes from one cancer centre was to analyse the reliability of the procedure, the pattern of failures during follow-up and the factors affecting the clinical outcome of patients. Between April 1995 and November 2001, 726 consecutive patients with primary cutaneous malignant melanoma underwent SLN biopsy with preoperative lymphoscintigraphy. The vital blue dye technique was used in 170 patients, and the blue dye technique combined with intraoperative lymphoscintigraphy in 556 patients. The primary melanoma sites were head and neck in nine patients, the extremities in 419 patients, and the trunk in 298 patients. The median Breslow thickness was 3.0 mm. All patients were followed closely, the median follow-up time being 34 months. The sentinel node(s) were successfully identified in 96% of patients. Intraoperative lymphoscintigraphy combined with the blue dye technique improved the SLN identification rate (technical success in 97.3% of cases) compared with the blue dye technique alone (technical success in 91.6%). The rate of failed SLN procedures was significantly (P = 0.007) lower in inguinal basins (3.1%) compared with axillary basins (7.9%). SLN metastases were detected in 147 patients (20.2%). The presence of SLN metastases correlated significantly with primary tumour thickness and ulceration (P < 0.001). The false-negative SLN biopsy rate was 4.66% (27 out of 579 SLN-negative patients). All but two node-positive patients underwent complete lymphadenectomy. Lymph nodes other than SLNs were found to contain metastases in 26.9% of patients (39 out of 145). The 5 year overall survival (OS) rate was 84% for SLN-negative patients and 40% for SLN-positive patients. Five variables showed a strong, statistically significant negative independent prognostic association with OS: positive SLN status (P = 0.000001), primary melanoma thickness > 4 mm (P = 0.0009), male gender (P = 0.001), more than one lymph node involvement (P = 0.02) and lymph node extracapsular extension (P = 0.03). SLN biopsy is currently a valuable and effective diagnostic procedure for the precise staging of patients with clinically N0 cutaneous melanoma. So far SLN biopsy seems to be the only accessible method for consciously oriented detection of nodal micrometastases in melanoma that would otherwise go undetected. SLN status is the most important factor proven to distinguish high and low risk melanoma patients.     

Sentinel lymph node navigation surgery for pancreatic head cancers

Recently, sentinel lymph node (SN) concept has been validated for gastrointestinal and breast cancers. Our previous study has shown that the No. 13 posterior pancreaticoduodenal lymph node group constitutes the major regional drainage site from primary tumors in the pancreatic head, and that the status of these nodes predicts that of the No. 16 abdominal paraaortic lymph node group. Based on these results, we have developed SN navigation surgery for pancreatic cancer, in the search for more curable and less invasive surgery. In brief, 2% patent blue dye is injected into the peritumoral area. Approximately 5 min later, one or more blue-stained nodes within the area of the No. 13 lymph node group are identified and excised for intraoperative frozen section examination. The subsequent surgical decision-tree is as follows: i) if No. 13 SNs are negative, an extended No. 16 lymph node dissection is not performed to reduce morbidity, and ii) when cancer is found, the No. 16 lymph nodes are dissected completely. Since July 1997, nine of 21 patients scheduled to undergo an extended curative surgery underwent SN biopsy. SNs within the area of the No. 13 lymph node group were identified in 8 (89%) patients. An extended No. 16 lymph node dissection was avoided in 4 SN-negative patients. The overall 3-year survival rate of the 21 patients was 36%, and 4 patients (three SN-negative and one SN-positive patients) with stage IVa disease were alive 3 years after surgery. Three SN-negative patients underwent an extended curative pylorus-preserving pancreaticoduodenectomy (PpPD) with combined portal vein resection, but without an extended No. 16 dissection. In conclusion, SN biopsy and curative PpPD can increase curability, reduce morbidity, and provide long-term survival in patients with locally advanced pancreatic head cancer as an alternative to routine extended No. 16 lymph node dissection.     

舌癌前哨淋巴结微转移检测的初步研究

目的 探索舌癌前哨淋巴结(Sentinel node, SN)微转移检测的适当方法及其预测颈部转移状况的功效.方法 使用γ探头法、术前核素扫描+γ探头法、γ探头法+术中亚甲蓝示踪法进行SN检测,以颈清扫标本的常规病理结果为金标准,评价各方法的功效.石蜡切片病理检查阴性的SN进一步行多层切片+免疫组化检查.结果 全组23例患者(其中初诊的cN0 20例、有手术史的cN0 1例、cN+2例)单用γ探头法,SN检出率为95.6%(22/23),假阴性率为10.5%(2/19),准确率为91%(20/22).5例cN0患者使用术前核素扫描+γ探头法,SN检出率为100%,均为cN0pN0,无假阴性.11例cN0患者使用γ探头探测+染料示踪法检测,全部定位到SN,无假阴性;多层切片+免疫组化检查微转移发现率为6.7%(3/45).结论 舌癌SN活检的初步研究显示出良好的应用前景,但还需进一步研究.术前核素扫描与术中γ探头法、生物染料法相结合是舌癌SN检测的适当方法.连续切片+免疫组化可提高微转移灶的检出率.     

Radioisotopic lymphatic mapping of the sentinel node in melanoma: importance of immunohistochemistry

BACKGROUND: Elective lymph node dissection (ELND) for patients with malignant melanoma is still controversial. A possible alternative could be biopsy of the first tumor draining lymph node, the sentinel node (SN), which can be identified by means of radionuclide techniques. AIM: Our study was undertaken to assess the accuracy of lymph node biopsy and to stress the importance of immunohistochemistry (IHC) in the pathological assessment of the SN for improved staging of the primary tumor. METHODS: We performed lymphoscintigraphy (LS) in 183 melanoma patients (89 with melanoma of the legs, 11 of the arms and 83 of the trunk). Our protocol consisted of preoperative peritumoral i.d. injection of 99mTc-labeled microcolloid to define the regional lymphatic basin and identify the sentinel node by means of planar scintigraphy. In 147 of the 183 cases a gamma probe (GP) was used during surgery to trace the SN. Vital blue dye was used during surgery in all cases. The SNs were excised for pathological examination. The pathological status of the SN was defined by means of examination of frozen sections, hematoxylin-eosin staining and immunohistochemistry for S-100 and HMB-45 MAb. RESULTS: At least one separate focus of activity was identified by LS in 182 out of 183 patients; in all 147 cases where a GP was used, it was successful in tracing the SN. LS with cutaneous mapping of the SN successfully guided the surgical excision in 177 of the 183 cases; in the 7 remaining cases, i.e. 7 out of 83 cases with SNs in the axillary basin, GP was not used and no elective node dissection was performed. Metastases were found in 39 of these 177 cases. In all 39 cases the SNs were the only positive nodes in the basin. Of the 39 metastases 18 were identified by means of frozen section, 12 by means of hematoxylin-eosin, and 9 by means of immunohistochemistry. We therefore emphasize the importance of immunohistochemistry in the pathology of LS for improved staging of the primary tumor.     

cN0舌癌前哨淋巴结定位方法研究

背景与目的：由于没有任何临床检查方法或生化标志能准确的评价临床NO（clinically negative neck,cNO)舌癌颈部淋巴结转移的状况。因而,目前对cNO舌癌的颈部治疗存在一定的盲目性。前哨淋巴结（sentinel node,SN)活检的应用为指导cNO舌癌患者颈部的个体化治疗提供了依据。本研究旨在探讨SN活检能否准确评价cNO舌癌的颈部淋巴结转移状况,寻找舌癌前哨淋巴结定位的最佳方法。方法：使用术前核素扫描法和术中亚甲蓝示踪法对24例cNO舌癌患者进行SN示踪,研究SN活检在评价cNO舌癌颈部淋巴结转移状况中的作用。对比核素扫描法,亚甲蓝示踪法,两法结合示踪法的优缺点。结果：3种方法全组SN检出率均为100%,24例中有4例手术标本发现有颈淋巴结转移（即隐匿性颈淋巴结转移,cNOpN^ ),SN活检对全组病例颈部淋巴结转移状况评价的准确率为100%。无假阴性;平均检出SN数目;核素扫描法3.5枚/例,亚甲蓝示踪法2.7枚/例,两法结合示踪法2.2枚/例。结论：核素扫描法和亚甲蓝示踪法均能有效地对cNO舌癌进行SN定位并准确地评价颈部淋巴结转移状况,两法结合SN示踪法最为准确。并且具有可操作性和实用性。     

Sentinel node-guided evaluation of drainage patterns for melanoma of the helix of the ear

The head and neck region, and especially the ear and its helix, is notorious for its ambiguous pattern of lymphatic drainage. Therefore, the primary nodal drainage basins in melanoma of the helix of the ear are often unpredictable. The aim of the study was to examine the value of sentinel lymph node biopsy in melanoma of the helix of the ear and to describe the natural history of the disease. Fifteen consecutive patients (14 men) with primary melanoma of the helix of the ear (median thickness, 1.2 mm; range, 0.7-10.0) underwent preoperative lymphoscintigraphy, followed by intraoperative lymphatic mapping, using blue dye in combination with a hand-held gamma probe and sentinel lymphadenectomy. The melanomas were characterized by low mitotic rate, low lymphocytic infiltrate, low spontaneous-regression rate, and mostly epitheloid cell type. In one patient, preoperative lymphoscintigraphy failed to demonstrate the draining nodes. The sentinel lymph nodes were identified and retrieved in all patients during surgery. In 13 patients (87%), they were found in the upper jugular lymphatic basin (level IIA); none were found in the retroauricular region. All sentinel lymph nodes were tumor-negative. At a median follow-up of 39 months (range, 12-73), all 15 patients were disease-free. In conclusion, sentinel lymph node biopsy for helix melanoma is an excellent alternative to elective lymph node neck dissection and superficial parotidectomy, with a high success rate and low morbidity. Melanoma of the helix of the ear has an indolent natural history.     

Sentinel node localization in primary melanoma: learning curve and results

Ninety primary melanoma patients were studied to investigate the importance of adopting the simultaneous use of patent blue dye (PBD) and lymphoscintigraphy plus gamma detection probe to locate the sentinel node (SN). In total 135 SNs in 105 basins were visualized preoperatively under a gamma camera after lymphoscintigraphy. When a SN was identified intraoperatively, its radioactivity level and colour were verified and documented. Two of the SNs seen on lymphoscintigraphy were not found. Using PBD 78.52% of the SNs were identified; 95.5% were identified using the gamma detection probe. Using both methods together 98.5% of the SNs were detected. Twenty-two patients (24.4%) had pathologically positive SNs. The surgical learning curve was assessed for the two techniques. The learning curve associated with the methodology was important in finding the SN when using PBD associated with lymphoscintigraphy, but not when the gamma detection probe was used; we found a statistically significant reduction in the percentage of stained SNs found using PBD in the initial 14 SNs biopsied compared with the subsequent 121 nodes. This is important as not all institutions have access to a gamma probe. The time required to identify each SN was documented and analysed. The duration of the procedure was significantly shorter for stained SNs than for non-stained SNs, which support the use of both PBD and the gamma probe. In conclusion, SN biopsy should be performed by surgeons and nuclear medicine doctors in co-operation, both methods being adopted simultaneously to reduce the percentage of procedure failures.     

Lymphatic mapping with intralesional tracer administration in breast carcinoma patients

BACKGROUND: The objectives of the study were to determine how often a sentinel lymph node is visualized by lymphoscintigraphy in breast carcinoma patients, how often the sentinel lymph node is identified during surgery, and the sensitivity of these procedures to identify the presence of axillary lymph node metastasis. METHODS: A total of 136 patients were enrolled in 2 hospitals. Preoperative dynamic and static lymphoscintigraphy were performed; in addition, both a vital dye and a gamma detection probe were used intraoperatively. The tracers were injected into the primary lesion. Sentinel lymph node biopsy was followed by completion axillary lymph node dissection. The sentinel lymph nodes and other axillary lymph nodes were examined routinely and by immunohistochemical staining. RESULTS: A sentinel lymph node was visualized by lymphoscintigraphy in 118 patients (87%). During the operation a sentinel lymph node was localized in 126 patients (93%). A total of 224 sentinel lymph nodes were harvested (average of 1.7 and range of 1-4 sentinel lymph nodes per patient). Of all the sentinel lymph nodes, 37 were blue (17%), 68 were radioactive (30%), and 119 were both blue and radioactive (53%). The sentinel lymph nodes contained metastatic disease in 56 patients (44%). Three sentinel lymph node biopsies were false-negative (sensitivity 95%). CONCLUSIONS: Sentinel lymph node biopsy with preoperative lymphoscintigraphy after intralesional tracer administration and intraoperative use of both a gamma detection probe and a vital dye is a reliable technique for staging the axilla of breast carcinoma patients.     

Preoperative ultrasonographic identification of the sentinel lymph node in patients with malignant melanoma

BACKGROUND: Dissection of the "sentinel lymph node" (SLN) as identified by lymphoscintigraphy is becoming increasingly important in the treatment of patients with malignant melanoma. The purpose of the current study was to determine whether the SLN also could be identified by ultrasound. METHODS: Sixty-seven patients with malignant melanoma (40 females and 27 males, with an average age of 48.8 years) in whom extirpation of the SLN was indicated underwent ultrasonography of the regional lymph nodes prior to preoperative lymphoscintigraphy. The location of the melanoma was the legs in 30 patients, the arms in 14 patients, and the trunk in 23 patients. During regional ultrasonography, the location of the lymph nodes that differed in the cortex/medulla ratio from the surrounding lymph nodes was marked on the skin corresponding to the planes of insonation (M1) when the probe was held vertically to the skin surface. After lymphoscintigraphy using technetium-99m, the position of a gamma probe at which the highest count rate vertical to the skin surface was recorded also was marked (M2). RESULTS: In the inguinal region, the agreement between M1 and M2 was found to be 100% (40 of 40 SLNs) and was 72.5% in the axilla (29 of 40 SLNs). In patients with melanomas located on the leg, the location of M1 and M2 agreed in 97% of cases (36 of 37 lymph nodes in 30 patients); in patients with melanomas located on the arms, the agreement was 76% (13 of 17 lymph nodes in 14 patients) and in patients with melanomas located on the trunk, the agreement was 75% (21 of 28 lymph nodes in 23 patients). The position documented by ultrasound relative to the neighboring structures of the SLN was confirmed intraoperatively in all cases. CONCLUSIONS: The results of the current study indicate that the SLN in patients with melanoma located on the limbs, especially the legs, are characterized by a specific sonomorphologic pattern. Preoperative sonography might constitute an important addition to lymphoscintigraphy in the planning of SLN biopsy.     

Sentinel node localisation: A new prospective in the treatment of nodal melanoma metastases.

Sentinel node (SN) mapping and biopsy is a procedure that accurately stages the regional lymph node (LN) basin. Defined patterns of lymphatic drainage allow intraoperative determination of the first (sentinel) lymph node in the regional basin, and the absence of metastatic disease in the SN accurately reflects the absence of melanoma in the remaining regional nodes. The use of radiocolloid and a hand-held gamma detecting probe (GDP) together with a vital blue dye provides optimal results, and allows for the successful identification of the SN in over 99% of the procedures. Close collaboration between surgeons, nuclear radiologists and pathologists is required to ensure optimal results. Examination of serially sectioned SNs by hematoxylin-eosin staining (H&E), immunohistochemical staining and perhaps in the near future RT-PCR should reduce the number of patients with missed microscopic melanoma in the regional lymph nodes. Furthermore, the survival benefit recently reported in patients with melanoma metastatic to regional nodes using high dose of interferon alpha-2b signals that the surgeons should aggressively examine patients for the presence of occult regional melanoma metastases. Intraoperative SN mapping and SN biopsy are cost-effective procedures that allows accurate identification of regional lymph nodes that contain metastatic melanoma.